Copyright © 2004 by the European Society of Cardiology.
Letter to the Editor
Long-term clopidogrel therapy in the drug eluting stent era: beyond CREDO and CURE-PCI: Reply
Interventional Cardiology Laboratory, Heart Centre, University Hospital, S-901 85 Umea, Sweden Tel.: +46-907-856925; fax: +46-901-37633
E-mail address: peter.eriksson{at}medicin.umu.se
Sir
In the trials comparing drug-eluting stents with bare metal stents, clopidogrel (in addition to aspirin) had been administrated for 2–6 months, and no increase in the incidence of stent thrombosis has been reported to date.1 However, I share Dr. Koh's and Dr. Kadr's concerns about delayed endothelialisation with drug-eluting stents. Although the optimal period of clopidogrel therapy after drug-eluting stent implantation is not known, clopidogrel is prescribed for 6 months after the implantation of a drug-eluting stent in our institution, which probably provides a wide margin of safety. In contrast, anti-platelet therapy was discontinued after the procedure in four out of the seven patients with a stent thrombosis in the study of Jeremias et al.,2 cited by Koh and Kadr. This is evidently not a strong argument for long-term clopidogrel therapy.
The clinical value of long-term therapy with clopidogrel in addition to aspirin has recently been called in question.3,4 Now the Management of ATherothrombosis with Clopidogrel in High-Risk Patients with Recent Transient Ischemic Attack or Ischemic Stroke (MATCH) trial5 also raises serious concerns about the safety of combining aspirin and clopidogrel long-term. In MATCH, clopidogrel and aspirin (
) were compared with clopidogrel alone (
) after an ischaemic stroke or transient ischaemic attack. There was a non-significant 0.73% absolute risk reduction in the composite of cardiovascular death, myocardial infarction or ischaemic stroke during 18 months of follow-up in patients receiving both aspirin and clopidogrel, compared with those receiving clopidogrel only. However, the absolute risk of life-threatening or major bleedings increased by 2.62% in patients who were given both aspirin and clopidogrel (
). Accordingly, the number needed to harm was only around 38.
Obviously, further study is needed to determine the risks and benefits of combining aspirin and clopidogrel for more than a few months in patients with atherothrombotic disease, including those receiving a drug-eluting stent. Remember Voltaire's bright reflection: "The best may be the enemy of the good".
References
- Hill RA, Yenal Y, Bakhai A et al. Drug-eluting stents: an early systematic review to inform policy. Review article. Eur. Heart J. 2004;25:902–919.
[Abstract/Free Full Text] - Jeremias A, Sylvia B, Bridges J et al. Stent thrombosis after successful sirolimus-eluting stent implantation. Circulation. 2004;109:1930–1932.
[Abstract/Free Full Text] - Khot UN, Nissen SE. Is CURE a cure for acute coronary syndromes? Statistical versus clinical significance. J. Am. Coll. Cardiol. 2002;40:218–219.
[Abstract/Free Full Text] - Eriksson P. Long-term clopidogrel therapy after percutaneous coronary intervention in PCI-CURE and CREDO: the "Emperor's New Clothes" revisited. Eur. Heart J. 2004;25:720–722.
[Free Full Text] - Diener H-C, for the MATCH investigators. Management of atherothrombosis with clopidogrel in high-risk patients with recent transient ischemic attack or ischemic stroke. Oral presentation at the 13th European Stroke Conference, May 13, 2004, Mannheim, Germany.
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